New Karolinska Hospital

Leveraging lifecycle building information modelling

(BIM) to optimize the construction, handover,
and operations and maintenance of the largest-
ever public-private partnership for a hospital
New Karolinska Solna Hospital
The challenge
The hospital public-private partnership faces difficult
circumstances, including a tight timeline, intense
public scrutiny and the ongoing operations of the
old hospital, and needs to be flexible enough to
accommodate future trends in healthcare.
The New Karolinska Solna (NKS) Hospital project is
considered the world’s largest public-private partnerships,
involving an overall investment of $3.0 billion (including
$1.6 billion for construction). Construction started in 2010
and is expected to be completed as well as to 2017.
When completed, the hospital – which will cover 320,000
square metres – will have over 12,000 rooms, 35 operating
theatres and 17 magnetic resonance imaging (MRI) units.
In addition to the core hospital building, the project
includes a parking garage, research building, technology
building (to handle the energy supply and deliveries
for the hospital), cancer treatment (radiation building),
as well as new roads connecting the buildings and
an entrance to a new subway station. Located in the
north of Stockholm, Sweden, the integrated hospital
and research complex will contribute crucially to the
development of the new Hagastaden neighbourhood.
To complicate matters, construction has to take
place without disrupting the normal operations
of the old Karolinska University Hospital and the
research-focused Karolinska Institute, which are
located nearby. Meeting the relevant noise, dust
and traffic level requirements was no easy task.
Moreover, given the significant public investment
and the institution’s global reputation, the project
is under close scrutiny from the media and the
general public, and is highly political. As a result, all
parties involved are under considerable pressure
to complete the project on time and on budget.
The construction of the NKS hospital should be viewed
in the wider healthcare context. Several trends are
relevant here. Populations in urban areas – Stockholm
is no exception – and an ageing population are raising
and changing the demand for hospital services; older
patients account for about half of hospital-bed occupation
globally. Advances in medical equipment and healthcare
delivery are producing a shift towards outpatient care.
The shortage and discontent of healthcare staff obliges
hospitals to improve working conditions. Over the lifetime
of the new hospital, these trends will play out further.
When completed, the hospital – which will
cover 320,000 square metres – will have
over 12,000 rooms, 35 operating theatres
and 17 magnetic resonance imaging (MRI)
units.
20 Shaping the Future of Construction
The idea
Leverage building information modelling across the
entire lifecycle to enhance design, construction,
operations and maintenance, and patient care,
and reduce the environmental impact by means
of methodical planning and the optimal use of
prefabrication and green technologies.
NKS aims to set new standards in patient care, integration
of healthcare and research, adaptability to future needs
and sustainability. The planners benchmarked leading
hospitals to identify optimal care procedures, workflows
and working conditions. The project incorporates many
innovations in the construction process and in operations
and maintenance (O&M), and now itself serves as the
benchmark for large and complex healthcare projects.
NKS is being delivered as a turnkey project under a public-
private partnership scheme in which the Stockholm City
Council signed an agreement with the dedicated project
company Swedish Hospital Partners – a joint venture of
Skanska Infrastructure Development and the UK pension
fund Innisfree – for designing and building the hospital
and operating it until 2040 (possibly even extending
the contract until 2055). Swedish Hospital Partners in
turn contracted Skanska Healthcare for the building
contract and Coor Service Management for the facility
management. The actual patient care – and everything
directly related to it, such as procuring medical equipment
– is the responsibility of the Stockholm City Council.
The contract mandated the use of building information
modelling (BIM). Mindful of the project’s vast size,
complexity and tight deadline, Skanska adopted
an advanced BIM model across the entire lifecycle,
creating a single data platform on which designers,
contractors and eventually facility managers could
collaborate (BIM Level 2). Starting with entering the
design specifications and performance requirements,
the architects and designers create 3D designs; every
object is then digitally stored in the model, with its
key attributes and exact location. Once completed,
the object list will contain about one million items.

The list and the model can be accessed from anywhere
via a Sharepoint System, enabling construction workers,
project managers, auditors, project owner or O&M
staff to access all information on their smartphones
or tablets – to inspect building plans, for instance, or
check on the progress of a specific construction task
via BIM 360 Field software also plays a key role in
preparing handover, by providing for “digital snagging”
– identifying potential issues and communicating them
in the form of a virtual punch list by by referencing
the BIM model (i.e. linking issues and location) – and
allowing digital quality control and virtual handovers.
The BIM model is also linked to an environmental library,
with all relevant information about all materials used in
the building; it expedited environmental certification,
and it can track materials for future replacement.
The comprehensive BIM model, populated during design
and construction, will then enhance O&M, making
that phase as efficient as well as operator and patient-
friendly as possible. By providing quick access to all
relevant data about objects – installation date, exact
location, actual usage – the BIM model will enable
predictive maintenance. By providing access to repair
manuals as well as identifying spare parts and indicating
remedial procedures, it enables faster and more effective
responses to typical failures. And by providing a digital 3D
representation of the building, it enables better planning
and quality control of daily operations, e.g. cleaning.
The project includes 29 automated guided vehicles
(widely used in the automotive industry), which will
autonomously conduct logistics within the hospital and
between the different buildings – for instance, delivering
medical supplies or transporting laundry. To minimize
on-site traffic, the vehicles will use separate underground
tunnels wherever possible. There is a central drop-off
point for deliveries. Staff will be informed of deliveries
via their mobile devices. For this purpose, the BIM
model’s object list serves as an address book.
New Karolinska Solna Hospital
The Stockholm County Council takes environmental
protection seriously and has made sustainability a priority
for this project, both in construction and O&M. The site
is classified as a Skanska Green Site with sustainable
solutions at all stages, and the construction process
was carefully planned to minimize the environmental
impact: an on-site concrete plant pre-empted 20,000
truck trips during the first three years, and an on-site
crushing plant reduced off-site transport activity as
well as landfill quantities. Where required, hybrid and
lower-emission trucks were used, and deliveries are
scheduled to minimize interference with local traffic
patterns. Construction waste is systematically analysed
with the aim to reduce it to zero (in 2010, only 5%
went to landfill). The work cabins are “environmental
cabins”, minimizing energy consumption through heat
pumps, and there is a recycling facility on-site.
Once completed, NKS will be climate-neutral, thanks
to its energy-efficient insulation, a geothermal energy
plant (with more than 160 bore holes, many of them 230
metres deep), the collection of food waste for biogas, and
energy-saving lifts. Inside the building, emissions from
chemical substances and compounds will be reduced,
and the entire building will be moisture-proofed to create
a healthy environment for staff, patients and visitors. All
waste will be separated and transported to an on-site
recycling facility through an underground piping system.
To avoid disrupting normal operations at the current
Karolinska University Hospital and the Karolinska
Institute, and to speed up the construction process
and exploit scale effects, the planners strove to
identify building components that were standard and if
possible prefabricated. The new hospital’s over 12,000
rooms consist of about 650 different standardized
room types. Or consider the 740 bathrooms pods,
completely prefabricated and pre-fitted by a supplier
in northern Sweden, which were transported in sealed
containers to the local storage facility and delivered on
site “just in time”, and lifted and pushed into position;
all that remained was for the workers to connect the
pre-fitted cables and wiring to the rest of the building
(bathroom modules of this kind are standard practice in
Shaping the Future of Construction 21
New Karolinska Solna Hospital
hotel construction, but had never before been used in
hospital construction). Prefabrication has been applied
to other components too, and helps to reduce manual
labour and avoid the need for scaffolding; prefabricated
mechanical and electric modules, for example, are simply
lifted to ceiling level and welded together in situ, and
prefabricated structural concrete elements and façade
modules are simply lowered into place by cranes.
The impact
The project has shown how the BIM model and
prefabrication can boost the speed and quality
of construction and commissioning, and has
taken a certified leading role in sustainability.
The use of BIM was contractually mandated, and
the business case for it has not yet been formally
proven here, but all project stakeholders agree that
it has been indispensable to the success of such a
complex project. Without it, the documentation and
the building work could never have reached the same
quality. Evaluating the business case for BIM can be
compared to evaluating the business case of using
mobile phone: the benefits are numerous, diverse
and obvious, yet hard to quantify exactly. Both costs
and benefits are distributed among participants and
increase with the number of users (network effects).
On a project involving over 12,000 rooms and a tight
schedule, the snagging and smooth handover would be
almost impossible, were it not for a cloud-based and
mobile-accessible BIM solution. Thanks to BIM 360 Field,
project managers and sub-contractors can communicate
and collaborate easily and productively, trade contractors
can digitally report completed works, and project
managers can pinpoint potential issues before handover.
Skanska (as main contractor) and the specialized trade
contractors can access up-to-date information and jointly
resolve issues very fast, coordination is much smoother
and speedier, and there are far fewer costly errors and
omissions, re-works and delays in commissioning. In
addition, auditors can access from anywhere and at any
time a detailed progress report of each task and object,
so handover of nearly finished rooms and floors (95%
22 Shaping the Future of Construction
completed) can proceed accurately and efficiently. Note
that the BIM model confers its complete range of benefits,
and repays the investment fully, only over the full lifecycle
of the building: it reduces O&M costs, boosts the quality
of healthcare provision through preventive maintenance
and effective repairs, and reduces operations costs
by enabling the use of automated guided vehicles.
The prefabrication strategy too has had a strong
positive impact on construction: it has reduced costs,
facilitated logistics, accelerated installation, improved
the quality of the building, and enhanced the health and
safety of the workforce. The prefabricated bathroom
modules illustrate these advantages. Traditionally,
finishing a bathroom requires a number of different
trade inputs and components – floor slabs, tiles,
handrails, towel hooks, washbasins and shower
units – to be applied in a very small room, resulting
very frequently in delays and quality issues.
In regard to sustainability, Skanska is not only meeting the
terms of Sweden’s Green Building Council certification
(Miljöbyggnad) as required by the Stockholm City
Council, but actually going beyond them, in line with its
ambition of becoming the world’s greenest construction
company. With parts of the main hospital building already
completed, NKS has achieved the accolade not only of a
preliminary Miljöbyggnad Gold rating, but also of a LEED
Gold rating (for the first part of the hospital, pending
verification after completion of the entire building) – one
of the first hospital buildings in Europe to do so.
In its normal operations, the building will be climate-
neutral with a heat-recovery system and its geothermal
plant (meeting 65% of the hospital’s heating and
cooling demand), as well as green roofs that will provide
insulation and retain surface water. The hospital’s
energy consumption will be 110 kWh/m2 requiring 40%
less energy than a comparable building constructed
according to current building norms. The purchased
energy will come from renewable energy sources. Note
that the Miljöbyggnad certification is based not just on
environmental protection, but also on a healthy indoor
environment – admitting sufficient daylight, for instance,
and cutting hazardous pollutants. Guided by the Swedish
Schedule 19 certificate and Byggvarubedömningen (as
part of the contract requirements – a building materials
assessment – the project team closely collaborated with
suppliers to eliminate controversial materials. For example,
they managed to secure PVC-free flooring, and placing a
large order stimulated the production of different colours.
BIM model confers its complete range of
benefits, and repays the investment fully,
only over the full lifecycle of the building.
 New Karolinska Solna Hospital

The barriers to innovation, Within the NKS project, systematic learning takes
place, by transferring personnel from phase to phase.
and the solutions In particular, lessons derived from work on the first part
of the main hospital building (Phase 4) are now being
When a hugely complex and demanding project relies
applied in Phase 5 and are facilitating all the remaining
heavily on technological innovations, the successful
building work – even before Phase 4 itself is actually
implementation of those innovations depends in turn
completed. A simple example: Fire safety consultants
on effective knowledge exchange between the key
are now being engaged in the very first general audits
stakeholders, early and pragmatic collaboration between
in order to identify potential issues early on (eliminating
project partners, and skills-building among suppliers.
a major source of delays in the previous phases).
The capital project is of very long duration – from the
One key challenge for the roll-out of BIM in the project
tender process in 2008 and financial closing in 2010,
(and in the industry as a whole) is the diversity of
through to completion of construction in 2017 (and O&M
the subcontractor landscape. Many smaller (trade)
until 2040) – so the project team has had to be amenable
contractors and suppliers lack the skill-sets and financial
and flexible, particularly in regard to integrating new
resources to invest in basic BIM, let alone to handle
technologies. Consider again the BIM solution outlined
competing BIM systems with their rival standards and
above. Thanks to technical advances and declining
data formats. To get sub-contractors and suppliers to
costs, staff can now readily use mobile devices to access
adopt BIM, therefore, Skanska had to put much effort
the BIM model on-site. The BIM 360 Field solution was
into persuading them of its benefits and providing training
actually introduced at NKS only in mid-2015, shortly
courses in its usage. In the future, BIM competence
before the handover of the first part of the main hospital
will be a criterion for selection of sub-contractors and
building. The technology now enables project managers to
suppliers, and will be included explicitly in their contracts.
inspect and sign off 250 rooms per week – a remarkable
pace that was almost unimaginable eight years ago.
Much effort has also gone into encouraging open
communication and increasing transparency about risks
The driving force behind the introduction of the software
and errors – not to assign blame, but to identify issues
was Clive Howard, Skanska Completion Manager, who
and to jointly address them before they become critical
had gained experience of cloud-based mobile snagging
and more costly. Sub-contractors and suppliers have duly
solutions on previous projects, and realized that the
become more open and collaborative, and can appreciate
technology would help enormously to prepare and
the benefits; for instance, by adding photos of the finished
handle the commissioning of such a complex project.
works and digitally signing off, they can cite later on-site
This transfer of personal experience from earlier projects
damage (a common problem) as the source of a problem.
has emerged as a key theme of the NKS project, and
has been deliberately orchestrated by Skanska.
A major challenge in the construction industry as a whole
is to reduce the lifecycle costs of assets. Normally, a
The building contract was awarded to Skanska Healthcare
contractor’s responsibility ends when the construction
– a joint venture between Skanska Sweden and Skanska
phase ends. At NKS, the long-term public-private
UK, which would exploit their experience of UK hospital
partnership contract – valid until 2040 – intensified the
projects. Ulf Norehn was selected as managing director
need for a longer-term perspective. One helpful step
for the project company Swedish Hospital Partners,
was to secure the early and active involvement of the
specifically because of his prior experience in delivering
facility manager, Coor Service Management. Facility
public-private partnerships for hospital projects in the
managers are often presented with a fait accompli,
UK. More broadly, Skanska staff members from several
whereas Coor was able to contribute operator expertise
countries (notably the UK, the US, Norway, Poland) have
far sooner, during the project’s design phase. And the
brought to the NKS project their experience of working
company will be able to commence the O&M phase
on BIM projects elsewhere, and will no doubt effect a
with the backing of a comprehensive BIM model –
reversed knowledge transfer in due course, contributing
something unprecedented in the hospital sector.
their NKS experience to other Skanska projects in future.
One example of longer-term cost-reduction through the
effective collaboration is the change in the IT landscape.
The original plan specified different physical servers
(one for each building control system), but the revised
plan specifies a common platform with standardized
virtual servers complemented by a common storage
and backup solution. This consolidation will reduce
IT costs during operations, but it was not budgeted
for, so Coor Service Management and Skanska
agreed to cover the additional costs jointly.

A recurring challenge for all BIM projects is the lack

of standardized data formats and systems. At NKS,
about 400 design consultants were involved, all

Shaping the Future of Construction 23

New Karolinska Solna Hospital
working on their own preferred system. The input from
these disparate systems had to be integrated into one
model. The BIM model, with its single data standard,
enabled a smooth transition from the construction
phase to the O&M phase, but if the original design
consultants are required to adjust design aspects in
future, they might struggle with the different format.
The recent transformative changes in the engineering and
construction sector is even outpaced by the rapid changes
affecting the healthcare sector, particularly the ongoing
changes in healthcare equipment, processes and client
demand. Various corresponding challenges have arisen for
the NKS project; for example, the Stockholm City Council
has several times required the relocation of heavy medical
equipment. In anticipation of such shifts, the building was
designed for flexibility, and can readily accommodate
changes in usage. Some examples: vertical load-bearing
columns are placed at both ends of the building, so the
room layout can be adjusted fairly easily; parts of the
façade can be removed fairly easily if large equipment
has to be moved into or out of the building; slabs are
sufficiently reinforced throughout the building in case heavy
medical machinery needs repositioning at short notice (a
MRI scanner can weigh more than 10 tonnes); and the
piping and wiring have a built-in overcapacity of 20% to
allow for extra demand or innovative uses in the future.
24 Shaping the Future of Construction
Lessons learned
–– Involve the facility manager or operator early
on in the process in order to improve lifecycle
performance
Selecting and promptly engaging the facility manager
Coor Service Management has helped the planners
to take a holistic, full-lifecycle perspective of the
project, and to ease the transition between phases,
especially between construction and O&M.
–– Rotate personnel across countries, projects and
project phases to enhance knowledge transfer
Innovation works best when those leading
and implementing it keep increasing their
own expertise and sharing it with others. By
seconding staff that have BIM experience on
similar projects elsewhere, the NKS project has
fostered knowledge exchange and optimized its
own implementation of the new technologies.
–– Deploy BIM across the project’s entire lifecycle
and its stakeholders to maximize the benefits
Every BIM model requires upfront investment,
and the benefits are spread over the lifecycle of
the project. BIM can speed up and enhance the
handover and commissioning. It is important that
contractors and facility managers should co-
invest in the model, and planners need to find
the right funding mechanism for that purpose.
–– Educate suppliers and sub-contractors on the
benefits of BIM, and provide training courses to
enable them to use it effectively
The project has shown how powerful a tool such
as BIM can be, especially when it is also used
by sub-contractors and suppliers. It is worth
putting considerable effort into persuading them
of the benefits of the BIM model, discussing
their concerns openly, and helping them with
relevant financing and training if necessary.
Case Study prepared by the Boston
Consulting Group as part of the Future
of Construction Project at the World
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